Total knee arthroplasty (TKA) is an effective treatment option for many patients, but a small group of patients are dissatisfied following TKA.» Alignment, in combination with balance, stability, and knee kinematics, is an important modifiable surgical factor that can affect patient outcomes. » Driven by the subset of dissatisfied patients after TKA, new techniques have evolved in the search for a more anatomic reconstruction of individual knee morphology and a more accurate approximation of the individual lower-extremity alignment.» There is a need to optimize 3 aspects of TKA to improve patient outcomes-mechanical tooling processes, implants that resurface the epiphysis, and techniques that respect the variable anatomy of patients.